Use of hyaluronidase to prevent perineal trauma during spontaneous delivery: a pilot study

Our objective was to compare the frequency, degree, and location of perineal trauma during spontaneous delivery with or without perineal injections of hyaluronidase (HAase). This was a randomized, controlled pilot study, conducted in a midwife‐led hospital birth center in São Paulo, Brazil. Primiparous women (N = 139) were randomly assigned to an intervention group (HAase injection, n = 71) or to a control group (no injection, n = 68). Significant differences were noted between the two groups in frequency of perineal trauma (intervention, 39.4%; control, 76.5%), degree of spontaneous laceration (intervention, 0.0%; control, 82.4%), and laceration located in the posterior region of the perineum (intervention, 54.2%; control, 84.3%). When episiotomy and second‐degree lacerations were considered together and women with intact perineum were excluded from the analysis, the difference between the groups was no longer significant. With the use of the HAase enzyme, the relative risk was 0.5 for perineal trauma and 0.0 for second‐degree lacerations. The present findings suggest that perineal injection of HAase prevented perineal trauma. These findings provide strong rationale for a larger follow‐up study.     

Perineal Outcomes and Maternal Comfort Related to the Application of Perineal Warm Packs in the Second Stage of Labor: A Randomized Controlled Trial

ABSTRACT: Background: Perineal warm packs are widely used during childbirth in the belief that they reduce perineal trauma and increase comfort during late second stage of labor. The aim of this study was to determine the effects of applying warm packs to the perineum on perineal trauma and maternal comfort during the late second stage of labor. Methods: A randomized controlled trial was undertaken. In the late second stage of labor, nulliparous women (n = 717) giving birth were randomly allocated to have warm packs (n = 360) applied to their perineum or to receive standard care (n = 357). Standard care was defined as any second‐stage practice carried out by midwives that did not include the application of warm packs to the perineum. Analysis was on an intention‐to‐treat basis, and the primary outcome measures were requirement for perineal suturing and maternal comfort. Results: The difference in the number of women who required suturing after birth was not significant. Women in the warm pack group had significantly fewer third‐ and fourth‐degree tears and they had significantly lower perineal pain scores when giving birth and on “day 1” and “day 2” after the birth compared with the standard care group. At 3 months, they were significantly less likely to have urinary incontinence compared with women in the standard care group. Conclusions: The application of perineal warm packs in late second stage does not reduce the likelihood of nulliparous women requiring perineal suturing but significantly reduces third‐ and fourth‐degree lacerations, pain during the birth and on days 1 and 2, and urinary incontinence. This simple, inexpensive practice should be incorporated into second stage labor care. (BIRTH 34:4 December 2007)     

Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women

OBJECTIVE: Our goal was to evaluate the relationship between obstetric perineal trauma and postpartum sexual functioning. STUDY DESIGN: Our study was carried out with a retrospective cohort design in 3 groups of primiparous women after vaginal birth: Group 1 (n = 211) had an intact perineum or first-degree perineal tear; group 2 (n = 336) had second-degree perineal trauma; group 3 (n = 68) had third- or fourth-degree perineal trauma. These sample sizes reflect a 70% response rate. Outcomes were time to resuming sexual intercourse, dyspareunia, sexual satisfaction, sexual sensation, and likelihood of achieving orgasm. RESULTS: At 6 months post partum about one quarter of all primiparous women reported lessened sexual sensation, worsened sexual satisfaction, and less ability to achieve orgasm, as compared with these parameters before they gave birth. At 3 and 6 months post partum 41% and 22%, respectively, reported dyspareunia. Relative to women with an intact perineum, women with second-degree perineal trauma were 80% more likely (95% confidence interval, 1.2--2.8) and those with third- or fourth-degree perineal trauma were 270% more likely (95% confidence interval, 1.7--7.7) to report dyspareunia at 3 months post partum. At 6 months post partum, the use of vacuum extraction or forceps was significantly associated with dyspareunia (odds ratio, 2.5; 95% confidence interval, 1.3--4.8), and women who breast-fed were > or = 4 times as likely to report dyspareunia as those who did not breast-feed (odds ratio, 4.4; 95% confidence interval, 2.7--7.0). Episiotomy conferred the same profile of sexual outcomes as did spontaneous perineal lacerations. CONCLUSIONS: Women whose infants were delivered over an intact perineum reported the best outcomes overall, whereas perineal trauma and the use of obstetric instrumentation were factors related to the frequency or severity of postpartum dyspareunia, indicating that it is important to minimize the extent of perineal damage incurred during childbirth.     

Perineal Injury in Nulliparous Women Giving Birth at a Community Hospital: Reduced Risk in Births Attended by Certified Nurse‐Midwives

Introduction : Our objective was to determine if there is a difference in rates of perineal injury sustained by nulliparous women attended by obstetricians compared with certified nurse‐midwives (CNMs) at a US community hospital. Methods : We analyzed retrospective data for 2819 women who spontaneously gave birth to singleton, vertex, term, live infants between 2000 and 2005. The independent variable was attendant type (obstetrician or CNM). The main outcome variables were intact perineum, episiotomy, and spontaneous perineal lacerations. Multivariate logistic regression was used to adjust for six potential confounders: macrosomia, maternal age, epidural anesthesia, oxytocin administration, medical insurance status, and ethnicity. Results : The odds ratios (ORs) for obstetrician‐attended births versus CNM‐attended births were significant for a spontaneous minor perineal laceration versus intact perineum (OR = 1.82; 95% confidence interval [CI], 1.33–2.48), spontaneous major laceration versus intact perineum (OR = 2.29; 95% CI, 1.13–4.66), and episiotomy use versus no perineal injury, with or without extension (OR = 2.94; 95% CI, 2.01–4.29). Discussion : We found that the prevalence and severity of perineal injury, both spontaneous and from episiotomy use, were significantly lower in CNM‐attended births. J Midwifery Womens Health 2010;55:243–249 c̊ 2010 by the American College of Nurse‐Midwives.     

A comparison of "hands off" versus "hands on" techniques for decreasing perineal lacerations during birth

Our goal was to determine the frequency, degree, and location of perineal lacerations and the neonatal outcomes associated with the use of two techniques of perineal protection--expectant ("hands off") and interventionist ("hands on")--during childbirth. We conducted a randomized controlled trial to compare the effectiveness of two techniques for perineum protection during spontaneous delivery. Study participants included 70 nulliparous expectant mothers, who were divided equally between the "hands off" and "hands on" groups (n = 35 per group). Perineal laceration occurred in 81.4% of the women. Among these, first-degree lacerations were predominant (82.5%). Lacerations in the anterior and posterior regions of the perineum occurred with similar frequencies. Laceration rates did not differ between the "hands off" and "hands on" groups (P > .05). Neonatal outcomes were similar in both groups. The use of "hands off" technique of perineal protection does not alter the frequency or degree of perineal lacerations in childbirth, relative to a "hands on" technique.     

Incidence, severity, and determinants of perineal pain after vaginal delivery: a prospective cohort study

OBJECTIVES: The purpose of this study was to determine the frequency of perineal pain in the 6 weeks after vaginal delivery and to assess the association between perineal trauma and perineal pain.Study design This was a prospective cohort study of parturients at 1 day, 7 days,' and 6 weeks' post partum in an academic tertiary obstetric unit in Toronto, Canada. Four hundred forty-four women were followed up, including women with an intact perineum (n=84), first-/second-degree tears (n=220), episiotomies (n=97), or third-/fourth-degree tears (n=46). Primary outcome was the incidence of perineal pain on day of interview; secondary outcomes were pain score measurements and interference with daily activities. RESULTS: Perineal trauma was more common among primiparous women, those with operative vaginal deliveries, and those with epidural analgesia during the second stage of labor. The incidence of perineal pain among the groups during the first week was intact perineum 75% (day 1) and 38% (day 7); first-/second-degree tears 95% and 60%; episiotomies 97% and 71%; and third-/fourth-degree tears 100% and 91%. By 6 weeks, the frequency of perineal pain was not statistically different between trauma groups. CONCLUSION: Acute postpartum perineal pain is common among all women. However, perineal pain was more frequent and severe for women with increased perineal trauma.     

A Randomized Study of Two Methods of Teaching Perineal Massage: Effects on Practice Rates,Episiotomy Rates,and Lacerations

ABSTRACT: This study examined the effects of two methods of teaching perineal massage on the rates of practice of perineal massage, of episiotomy, and of lacerations in primiparas at birth. Couples in 20 randomly selected sections of four prenatal class series received routine printed and verbal instruction and a 12-minute video demonstration of perineal massage, or only the routine printed and verbal instruction. Women reported their practice rates in daily diary records, which were mailed to the researcher weekly. Hospital records provided delivery data. Of the 83 women, 23 (28%) practiced perineal massage: 16 (35.6%) in the experimental group, 7 (18.4%) controls. Even though the rate of practice almost doubled among experimental group women, the videotape instruction method was statistically nosignificant. Episiotomy and laceration rates were not affected by teaching method. More severe lacerations occurred among the experimental group; however, the control group had almost four times as many severe (21%) as minor (5.3%) lacerations. The experimental group had twice as many severe (28.9%) as minor (13.3%) lacerations. These results were also nosignificant.     

Episiotomy and perineal tears presumed to be imminent: randomized controlled trial

BACKGROUND: The indication of the restricted use of episiotomy at tears presumed to be imminent is not clear. METHODS: Randomized controlled trial with two perineal management policies. Use of episiotomy: (a). only for fetal indications and (b). in addition at a tear presumed to be imminent. Participants: 146 primiparous women with an uncomplicated singleton pregnancy at >34 weeks of gestation. For the intention-to-treat analysis those 109 women were included who vaginally delivered a live full-term baby between January 1999 and September 2000: 49 women in group a, 60 in group b. OUTCOME MEASURES: Reduction of episiotomies, increase of intact perinea or only minor perineal trauma (intact perineum and first-degree tears), third-degree tears, anterior perineal trauma, perineal pain in the postpartum period, pH of the umbilical artery, Apgar scores, maternal blood loss. RESULTS: Episiotomy rates were 41% in group a and 77% in group b (p < 0.001). Women in the restrictive policy group had a greater chance of an intact perineum (29% vs. 10%; p = 0.023) or only minor perineal trauma (39% vs. 13%; p = 0.003) and had significant lower pain scores postpartum at different activities. There were no statistically significant differences with regard to third-degree tears, anterior trauma, pre- and postpartum hemoglobin concentrations, Apgar scores and pH of the umbilical artery. CONCLUSIONS: Avoiding episiotomy at tears presumed to be imminent increases the rate of intact perinea and the rate of only minor perineal trauma, reduces postpartum perineal pain and does not have any adverse effects on maternal or fetal morbidity.     

Are Asian American women at higher risk of severe perineal lacerations?

Objective: To evaluate whether Asian race is an independent risk factor for severe perineal lacerations.

Methods: We performed a nationwide population-based retrospective cohort study examining the relationship between Asian race and severe perineal lacerations (third and fourth degree). The data were collected from the 2012 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). Characteristics of Asian American women were compared with those of non-Asian women. The primary outcome of interest was severe perineal lacerations. Multivariable logistic regression was used to refine the associations between Asian race and severe perineal lacerations while adjusting for confounding effects. Results were compared with previously published data using a pooled odds ratio.

Results: 2,270,044 Women with singleton vaginal deliveries were identified, and 120,452 (5.3%) were Asian. After adjusting for confounders, Asian women were more likely to experience severe perineal lacerations than any other racial group (3.5% versus 6.3%, adjusted odds ratio [aOR] 1.50, 99% CI 1.29–1.74, p?p?Conclusion: Asian race is an independent risk factor for severe perineal lacerations in the United States.     

Maternal Position at Midwife‐Attended Birth and Perineal Trauma: Is There an Association?

ABSTRACT: Background: Most women will sustain some degree of trauma to the genital tract after vaginal birth. This study aimed to examine the association between maternal position at birth and perineal outcome in women who had a midwife‐attended, spontaneous vaginal birth and an uncomplicated pregnancy at term. Methods: Data from 3,756 births in a major public tertiary teaching hospital were eligible for analysis. The need for sutures in perineal trauma was evaluated and compared for each major factor studied (maternal age, first vaginal delivery, induction of labor, not occipitoanterior, use of regional anesthesia, deflexed head and newborn birthweight >3,500 g). Birth positions were compared against each other. Subgroup analysis determined whether birth positions mattered more or less in each of the major factors studied. The chi‐square test was used to compare categorical variables. Results: Most women (65.9%) gave birth in the semi‐recumbent position. Of the 1,679 women (44.5%) who required perineal suturing, semi‐recumbent position was associated with the need for perineal sutures, whereas all‐fours was associated with reduced need for sutures; these associations were more marked in first vaginal births and newborn birth weight over 3,500 g. When regional anesthesia was used, semi‐recumbent position was associated with a need for suturing, and lateral position associated with a reduced need for suturing. The four major factors significantly related to perineal trauma included first vaginal birth, use of regional anesthesia, deflexed head, and newborn weight more than 3,500 g. Conclusions: Women should be given the choice to give birth in whatever position they find comfortable. Maternity practitioners have a responsibility to inform women of the likelihood of perineal trauma in the preferred birth position. Ongoing audit of all clinicians attending births is encouraged to further determine effects of maternal birth position and perineal trauma, to investigate women's perception of comfortable positioning at birth, and to measure changes to midwifery practice resulting from this study.     

Perineal analgesia with an ice pack after spontaneous vaginal birth: a randomized controlled trial

Introduction: This study evaluated the effectiveness of an ice pack applied for 20 minutes to alleviate perineal pain after spontaneous vaginal birth. Methods: We conducted a randomized controlled trial at the Amparo Maternal Birth Center in São Paulo, Brazil. Study participants included 114 nulliparous women divided into 3 groups (n = 38 per group): experimental (ice packs on the perineum), placebo (water packs at set temperature), and control (no treatment). Results: A numerical scale (0 to 10) was used for pain assessment. A comparison of the average pain at the beginning and after 20 minutes showed a significant reduction of pain (P < .001) in the 3 groups, and the experimental group had a lower average score for pain compared with the control group (1.6 versus 3.3, P = .032). Discussion: The use of ice packs for 20 minutes was effective for perineal pain relief after vaginal birth.     

Is It Necessary to Suture All Lacerations After a Vaginal Delivery?

Background: Midwives tend to leave minor perineal lacerations to heal spontaneously, and clinical experience and studies show that women can suffer from their stitched lacerations. The study purpose was to determine any differences in the healing process and experience of minor perineal lacerations when they were sutured or not sutured. Methods: Eighty term pregnant primiparas with minor perineal lacerations of grades I–II were randomized after childbirth. The experimental group was nonsutured and the control group was sutured. A follow‐up examination was performed at 2 to 3 days, 8 weeks, and 6 months after the delivery. Participants were asked about the type of discomfort, and the effect of the laceration on breastfeeding and sexual intercourse. Results: No significant differences were found in the healing process. The type of pain differed between the groups, but the amount of discomfort was the same. The sutured group had to visit the midwife more often because of discomfort from the stitches. Sixteen percent of the women in the sutured group, but none in the nonsutured group (p= 0.0385), considered that the laceration had had a negative influence on breastfeeding. Conclusions: Minor perineal lacerations can be left to heal spontaneously. The benefits for the woman include the possibility of having a choice, avoiding the discomfort of anesthesia and suturing, providing positive affects on breastfeeding.     

The prevalence of enduring postnatal perineal morbidity and its relationship to perineal trauma

OBJECTIVE: to investigate the prevalence of enduring postnatal perineal morbidity and its relationship to perineal trauma. DESIGN: a retrospective cross-sectional community survey of postnatal women. PARTICIPANTS AND SETTING: a total population sample of 2100 women were surveyed from two maternity units within Birmingham. Women were identified from the Trust's computerised Maternity Information System (MIS). METHODS: Women were surveyed using a self-administered postal questionnaire 12 months after birth. The questionnaire included self-assessment of perineal pain, perineal healing, urinary incontinence, flatus incontinence, faecal incontinence, sexual morbidity and dyspareunia. FINDINGS: a response rate of 23.3% was achieved (n=482). A high level of perineal morbidity was reported (53.8% stress urinary incontinence, 36.6% urge urinary incontinence, 9.9% liquid faecal incontinence, 54.5% with at least one index of sexual morbidity). Women with perineal trauma reported significantly more morbidity (sexual morbidity, dyspareunia, stress and urge urinary incontinence) than women with an intact perineum. Women with perineal trauma also resumed sexual intercourse later than women with an intact perineum. Women with a first- or second-degree tear reported significantly more perineal morbidity (stress incontinence, sexual morbidity) than women with an intact perineum, and resumed sexual intercourse later. However, a high percentage of women with an intact perineum also reported new-onset perineal morbidity: stress urinary incontinence (34.8%); urge urinary incontinence (19.5%); flatus incontinence (13.8%); and dyspareunia (25.3%), highlighting that enduring perineal morbidity can occur irrespective of perineal trauma. CONCLUSION: enduring postnatal perineal morbidity is common in women with all types and grades of perineal trauma and intact perineum after childbirth. This highlights the need for further debate and research into the prevalence and experience of postnatal morbidity.     

A prospective observational study on tears during vaginal delivery: occurrences and risk factors

BACKGROUND: To ascertain the occurrence and distribution of various types of I-IV degree tears, during childbirth, and analyze risk factors for perineal II degree tears. MATERIALS AND METHODS: A total of 2883 consecutive vaginal deliveries, during 1995-97 at Sahlgrenska University Hospital in G?teborg Sweden, were included. All tears were classified according to an especially designed protocol, and risk factors for II degree tears were evaluated by use of univariate and logistic regression analysis. RESULTS: Only 6.6% of nulliparous parturients had no detectable tear as compared to 34.2% in parous women. Almost half of the women suffered from a II degree tear during birth, and a higher proportion of nulliparous (16.6%) than parous (9.4%) women had extensive perineal lacerations. In addition, nulliparous were more likely than parous parturients to be subjected to a perineotomy (18.1% versus 5.6%). Stepwise logistic regression analysis revealed that the following factors remained independently associated with II degree tear: slight perineal edema, high infant weight, excellent visualization of perineum, increasing age of the mother, excellent cooperation of the women, protracted second phase (> 60 min) and duration of second phase < 30 min. CONCLUSIONS: The majority of women (78%) undergoing childbirth had a tear and 47.1% suffered from perineal lacerations. Nulliparous women were more likely to have severe perineal lacerations or episiotomies. Similar risk factors were found for II degree tears as previously shown for III/IV degree tears.     

Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States

OBJECTIVE: The purpose of this study was to estimate the incidence of urinary and bowel incontinence in relation to anal sphincter laceration in primiparous women and to identify factors that are associated with anal sphincter laceration in a unit that uses primarily midline episiotomy. STUDY DESIGN: From January 1, 1997, to March 30, 2000, 2941 questionnaires concerning pelvic floor function 6 months after delivery were mailed to primiparous women who were delivered vaginally at the University of Michigan Medical Center. Charts were reviewed for 2858 deliveries to assess the use of episiotomy and the degree of perineal trauma, along with demographic and pertinent delivery variables. There were 943 women who completed the urinary function questionnaire and 831 women who completed the bowel function questionnaire. Univariate analysis was performed on all covariates. Multiple logistic regression was used for the analysis of the presence of third- or fourth-degree lacerations as the outcome. RESULTS: Nineteen percent of the women who completed the survey had sustained third- or fourth-degree lacerations during childbirth. The women in the sphincter laceration group were more likely (23.0%) to have bowel incontinence than the women in the control group (13.4%) (P<.05). The incidence of worse bowel control was nearly 10 times higher in women with fourth-degree lacerations (30.8%) compared with women with third-degree lacerations (3.6%, P<.001). Macrosomia (odds ratio, 2.19; 95% CI, 1.61, 2.99), forceps-assisted delivery (odds ratio, 4.75; 95% CI, 3.43, 6.57), and vacuum-assisted delivery (odds ratio, 3.51; 95% CI, 2.64, 4.66) were associated with higher risks of third- and fourth-degree lacerations. Midline episiotomy (odds ratio, 2.24; 95% CI, 1.81, 2.77), but not mediolateral (odds ratio, 0.66; 95% CI, 0.375, 1.19), episiotomy was associated with anal sphincter lacerations. More than one half of the women had new onset of urinary incontinence after delivery and reported several lifestyle modifications to prevent leakage. CONCLUSION: Women with third- and fourth-degree lacerations were more likely to have bowel incontinence than women without anal sphincter lacerations. Fourth-degree lacerations appear to affect anal continence greater than third-degree lacerations.     

SPONTANEOUS PUSHING DURING BIRTH: Relationship To Perineal Outcomes

Vaginal birth is a recognized factor in perineal tissue damage and postpartum perineal pain. This study examined outcomes of 39 primiparous women who had spontaneous vaginal births. In a retrospective survey, women were asked to describe the type of pushing used to give birth and what the level of pain had been in the perineal (or vaginal) area during the first week postpartum. Labor and delivery chart data documented extent of episiotomy and/or laceration sustained. Eleven (28%) women reported using spontaneous bearing down efforts, and the remaining 28 (72%) were directed. Women who used spontaneous pushing were more likely to have intact perineums postpartum and less likely to have episiotomies, and second or third degree lacerations (χ² [3, N = 39] = 8.1, P = .043). Other variables, such as maternal age, infant birth weight, length of second stage, provider type, and use of epidural, did not demonstrate a significant difference in perineal outcome. Further analysis showed a significant relationship between the extent of perineal disruption and pain (F [3,30] = 5.08, P = .005).     

Multivariable evaluation of term birth weight: a comparison between ultrasound biometry and symphysis-fundal height

Abstract

Objective: To determine whether perineal massage during the second stage of labor using oil enriched with vitamins, increases the chances of delivering with an intact perineum as compared to perineal massage using pure liquid wax.

Method: A prospective, randomized, double-blind study was conducted. Women were assigned to liquid wax (jojoba oil) versus purified formula of almond and olive oil, enriched with vitamin B1, B2, B6, E and fatty acids. The caregivers used the oils during the second stage of labor.

Results: A total of 164 women undergoing vaginal delivery were recruited. No significant differences regarding perineal lacerations, number of sutures and length of suturing were noted between the two groups. Likewise, while analyzing separately nulliparous and multiparous women, no significant differences were noted. Controlling for birth weight >4000?g, using the Mantel–Haenszel technique, no association was noted between perineal lacerations and the type of oil used (weighted OR?=?0.9, 95% CI 0.3–2.4; p?=?0.818).

Conclusion: The type of the oil used during the second stage of labor for prevention of perineal tears has no effect on the integrity of the perineum. Accordingly, it seems that there is no perfect oil.